Pharmaceutical combination preparations containing erythropoietin and modified haemoglobins

ABSTRACT

A kit comprising an erythropoietin and a modified hemoglobin is disclosed.

PRIORITY TO RELATED APPLICATIONS

This application is a Continuation of Ser. No. 10/140,682, filed May 8,2002, which is a continuation application of National Phase (PCT) patentapplication Ser. No. 09/446,378, filed Feb. 7, 2000, which is now U.S.Pat. No. 6,440,932, issued Aug. 27, 2002.

BACKGROUND OF THE INVENTION

The invention is concerned with pharmaceutical combination preparationscontaining erythropoietin preparations and one or more modifiedhaemoglobins. The combination preparations are especially useful for thetreatment of manifest anaemias.

The object of the present invention is a pharmaceutical combinationpreparation which comprises a) individual administration forms of anerythropoietin preparation suitable for the individual dosing of theactive substance in an amount of 3,000-7,000 U and b) 50-100 ml of oneor more modified haemoglobins, with the erythropoietin preparation andmodified haemoglobin being present in separate administration forms orin a single administration form.

The macromolecule ferritin (molecular weight at least 440 kD dependingon the iron content) plays a significant role in the diagnosis ofanaemias. An estimation of the fullness level of the iron reservoir ispossible by determining the ferritin and the transferrin saturation (M.Wick, W. Pingerra, P. Lehmann “Ferritin in iron metabolism and diagnosisof anaemias”, pages 5-22, 38-50, 65-77, 94-97, 2^(nd) expanded edition1994, published by Springer Vienna, New York), with the totality of theiron stored as basic ferritin in the depot organs liver, spleen and bonemarrow amounting to about 800-1200 mg. A lower ferritin concentration isthe definitive characteristic for detecting iron deficiency states andtheir difference from other causes of hypochronic anaemia, such as e.g.chronic inflammations and tumours.

It is known to treat transfusion-mediated anaemias in haemodialysispatients with recombinant erythropoietin (rhEPO), with it beingnecessary as a rule to carry out an iron substitution in parallel to theEPO therapy. This iron substitution is effected by the intravenousadministration of iron (III) salts, with two intravenously administrableiron preparations being available on the German medicament market atpresent. These are the medicaments “Ferrlecit” and “Ferrum Vites”.“Ferrlecit” is an iron (III) gluconate complex, while “Ferrum Vites” isan iron (III) oxide saccharate complex.

It has, however, become evident that in the case of manifest anaemiaswith manifest iron deficiency and iron utilization disorders (<30 mg/dlferritin) iron substitution with the mentioned preparations hasdisadvantages, since for the treatment of manifest anaemias relativelylarge amounts of a pharmacologically harmless iron salt have to beinfused. The use of the aforementioned iron preparations holds thepossibility of unexpected circulatory reactions up to collapse,especially when large amounts have to be injected relatively rapidly.

In WO 96/15805 there is described a haemoglobin therapy forhaemodialysis according to which very low doses of stroma-freehaemoglobin are administered over a period of 10 to 45 minutes in orderto achieve a haemostabilization and to avoid a lowering of bloodpressure in sensitive patients. However, this described therapy is notsuccessful in the case of manifest iron deficiency anaemias.

Also, WO 95/24213 describes the use of natural or recombinanthaemoglobin or their chemically modified derivatives for anemiatreatment. Furthermore, this document discloses the combinedadministration of one of the aforementioned haemoglobins with one ormore haematopoietic growth factors, inter alia with EPO. Examples 4 and5 as well as some of the Figures show that a combined administration ofEPO and rh haemoglobin lead to an increased haematopoesis.

However, this document does not disclose a practical therapeutic regimefor an optimal regulation and treatment of patients with manifestanaemias. Also, it is not evident therefrom, as in the case of patientstreated with EPO, that it is possible to produce an optimal EPO effectwithout avoiding an EPO resistance.

SUMMARY OF THE INVENTION

It has now been found that the use of relatively high infusion amountsof 50-100 ml of haemoglobin (about 100-200 mg Fe²⁺) together with3,000-7,000 U of EPO is surprisingly advantageous for the treatment ofmanifest anaemias (the abbreviation “IU” can also be used in place ofthe abbreviation “U” for International Units).

The object of the invention are accordingly also combinationpreparations which contain 3,000-7,000 U of EPO and 50-100 ml of one ormore modified haemoglobins, with the EPO and the modified haemoglobinbeing present in separate administration forms or in a singleadministration form.

DETAILED DESCRIPTION OF THE INVENTION

In accordance with the invention 3,000-7,000 U of an erythropoietinpreparation and 50-100 ml of one or more modified haemoglobins are usedas the optimal dose depending on the clinical picture of the anaemia.Thus, in the case of manifest anaemias without iron distributiondisorders, a high dose of Fe²⁺, about 80-100 ml (about 160-200 mg Fe²⁺),preferably 89-95 ml, in the form of a modified haemoglobin and a lowerdose of EPO between 3,000 and 5,000 U is administered in accordance withthe invention.

When there are iron distribution disorders in the case of manifestanaemias, a higher EPO dose of about 5,000-7,000 U of EPO, preferably6,000-7,000 U, especially about 7,000 U of EPO, and a high Fe²⁺ dose,about 80-100 ml, preferably about 100 ml, in the form of one or moremodified haemoglobins is preferably administered.

For the treatment of iron utilization disorders in the case of manifestanaemias the combination preparation in accordance with the inventionpreferably contains 3,000-7,000 U of EPO and 80-100 ml of a modifiedhaemoglobin, preferably about 5,000 U of EPO, and about 100 ml of one ormore modified haemoglobins. For the treatment of manifest irondeficiency anaemias the combination preparation likewise preferablycontains 3,000-7,000 U of EPO and 80-100 ml of a modified haemoglobin.

As modified haemoglobins in the meaning of the invention there aresuitable in principle all haemoglobins described in WO 95/24213 page 20,line 15 to page 27, line 2. In particular, these are also cross-linkedhaemoglobins or cross-linked haemoglobin polymerizates, such as e.g.diacetylsalicylic acid (diaspirin), cross-linked haemoglobin (DCL-Hb) orother blood substitutes based on modified haemoglobins. For example, thefollowing preparations come into consideration as modified haemoglobins:Herm Assist® (Baxter; DCL human Hb); PolyHerme® (Northfield, Upjohn,human Hb, cross-linked and polymerized); Hemopure® (Biopure, Upjohn;bovine Hb, polymerized); Optro® (Somatogen, Eli Lilly; recombinant humanHb); HemOlink® (Hemosol, Fresenius; human Hb, cross-linked andpolymerized); PEG-modified bovine Hb (manufactured by Enzon;polyethylene glycol-modified Hb); polyoxyethylene-modified human Hb(manufactures Apex and Ajinimoto). The haemoglobins can also be used inaccordance with the invention in the form of haemoglobin preparationswhich contain pharmaceutically compatible adjuvants known per se. Suchpreparations are described, for example, in WO 95/24213.

As suitable erythropoietin preparations in the meaning of the presentinvention there come into consideration those active substances whichare comparable with respect to the physiological effect of human EPOs.Suitable EPO preparations are, for example, recombinant human EPO(rhEPO; see European Patent EP 0,205,564 or EP 0,411,678) or alsocorresponding modifications of these proteins. As modifications therecome into consideration, for example, such proteins with molecularweights higher or lower than 34,000 Da (molecular weight of urinaryEPO), likewise isoforms of the enzyme or proteins with differentglycosylation. In particular, proteins chemically modified by PEG(polyethylene glycol) can also be used. Further, there basically alsocome into consideration such proteins which are derived by deletions,substitutions or additions from the amino acid sequence of the naturalEPO with a length of 166 amino acids. These proteins have essentiallycomparable physiological properties to rhEPO. In particular, theseproteins have biological properties which cause bone marrow cells toincrease the production of reticulocytes and red blood corpuscles and/orto increase haemoglobin synthesis or iron uptake. In place of theseproteins there can also be used low molecular substances, which aredenoted as EPO mimetics, and which bind to the same biological receptor.These mimetics can preferably also be administered orally. The amount ofsuch proteins or mimetics to be administered is determined by comparingthe biological activity between EPO and these active substances.

The concentrations in accordance with the invention of EPO andhaemoglobin-Fe²⁺ permit in their combination an optimal anaemiatreatment, especially the treatment of manifest anaemias. The treatmentwith the combination preparation is preferably effected once weekly,whereby the amount of haemoglobin of 300 ml per week should not beexceeded (e.g. 3×100 ml infusions).

In the meaning of the present invention there should be understood underthe term “combination preparation” not only those medicament packs inwhich the EPO preparation and the haemoglobin are presented injuxtaposition in a finished marketable unit pack (so-called combinationpack), but also those medicament packs which either contain a suitableamount of an EPO preparation or a suitable amount of a haemoglobin inthe form of the respective individual preparations, with the individualpreparations with respect to the amount of contents being presented suchthat they can be administered in the meaning of the invention for thecombined dose with the respective other preparation. In these casesthere is usually enclosed with the preparations from the pharmaceuticalmanufacturer or the medicament importer a medicament package insertwhich is required by law in many countries and in which are containeddirections or information concerning the combined dose of the individualpreparations.

The combination preparations can preferably be present in a singleadministration form in which the respective amounts of the EPOpreparation and the haemoglobin are present in juxtaposition in onecontainer.

This can be e.g. an injection solution or infusion solution or itslyophilizate, which, for example, is filled into ampoules. Thisadministration form has the advantage that the EPO is stabilized by themodified haemoglobin during the production and storage of theadministration form. In the case of a lyophilizate, the EPO, after itsdissolution, is activated by the modified haemoglobin. The fixedcombination of the two active substances in the form of a lyophilizatehas the further advantage that it can be handled simply and safely. Thelyophilizate is dissolved in the ampoule by the addition ofpharmaceutically usual injection media and is administeredintravenously.

It is also possible to administer the EPO preparation and the modifiedhaemoglobin in the form of separate pharmaceutical formulations (freecombination) simultaneously or, however, also in succession. This freecombination, which can be made available in a unit pack, has theadvantage of greater flexibility. Thus, these administration forms alsoenable the modified haemoglobins to be administered 1-3 days prior tothe EPO administration.

This free combination, which can be made available in a single unit pack(medicament pack) also has the advantage that each patient to be treatedcan be prescribed a particular individual amount of an EPO preparationand of a haemoglobin. Furthermore, these combination preparations offerthe advantage of greater safety when performing the therapy, since ineach case the optimal synchronized amount of the individual preparationis fixed. A safe therapy and simple handling by the personnel performingthe treatment or in the area of self medication performed by patients isguaranteed by the combination preparation in accordance with theinvention.

Where the EPO preparation is made available as a lyophilizate, themedicament packs (combination packs) contain the corresponding amount ofthe EPO preparation in glass ampoules or in cartridges. The haemoglobincan be present in solid form (lyophilizate) or also in liquid form in aseparate container. Further, the combination pack preferably contains areconstitution solution in order to dissolve either the EPO lyophilizatealone or also together with the haemoglobin. If the haemoglobin ispresent as a ready-for-use solution, the solution can be mixed togetherwith the EPO solution when the combined administration of EPO andhaemoglobin has to be effected. Basically, the haemoglobin can also bemade available as a concentrate for addition to conventional infusionsolutions, by which means a longer administration over several hours canbe effected.

Combination preparations in the meaning of the present invention arealso those unit packs which in each case make available individualadministration forms of the erythropoietin preparations or of thehaemoglobin as independent medicaments, with the individual preparationsbeing provided such that they contain the requisite amounts of theindividual substances for the combination in accordance with theinvention of the EPO preparation and the hemoglobin. As a rule, themedicament packs contain the previously described package insertcontaining corresponding instructions for the combined administrationwith EPO or with haemoglobin in the required amount. A correspondinginstruction can also be present as a pack imprint on the medicament pack(secondary packaging) or on the primary packaging (ampoule, blisterstrips, etc.). Thus, in the case of the EPO-containing medicament with3,000-7,000 U of EPO it is, for example, indicated thereon that thispreparation should especially be administered together with ahaemoglobin preparation containing 50-100 ml of one or more modifiedhaemoglobins. In the case of the haemoglobin preparation there is areverse indication to the combined administration with 3,000-7,000 U ofan erythropoietin preparation.

A further possibility for providing the EPO preparation comprises makingavailable corresponding multi-dose preparations which contain the EPOpreparation in higher amounts compared with individual doses. Thesepreparations are especially suitable for use in clinics in which a largenumber of patients are treated daily. These multi-dose preparationscontain the EPO preparation in doses of up to 500,000 U, especially upto 100,000 or 50,000 U. The multi-dose preparations have the advantagethat they permit the skilled medical personnel to withdraw any dosage ofthe EPO preparation, for example by withdrawing corresponding amounts byvolume of the finished injection solution. This is especiallyadvantageous in the treatment of patients with different dosagerequirements of the active substance or in the treatment of children inwhich a lower dosage of the EPO preparation is required. From aninjection solution of, for example, 100,000 U of EPO, preferably freshlyprepared at the beginning of the day, there can be performed,circumstances permitting, all patient treatments required during thisday without the need to prepare separate injection solutions for each ofthe individual patients. This can lead to a significant time saving orto an easing of the burden of work for skilled medical personnel.Preferably, the individual EPO dosages are withdrawn in the range of3,000 U, 5,000 U and 7,000 U.

The multi-dose preparations can also be present in the form ofsolutions, which are filled into cartridges. These cartridges aresuitable for use in so-called pens, which permit administration bypatients themselves and an individual dosage withdrawal. For example,these cartridges contain the EPO preparation in an amount of 10,000 or20,000 U, whereby different dosing intervals can be realized byappropriate adjustment of the withdrawal volume.

The production of the pharmaceutical administration forms of theinvention is effected according usual processes known in galenicaltechnology with pharmaceutically usual adjuvants. The process for theproduction of the pharmaceutical combination preparation in accordancewith the invention and the pharmaceutical unit pack, which contains thecombination of preparations in accordance with the invention, arelikewise objects of the invention.

In carrying out the therapy, the diagnostic parameters ferritin andtransferring saturation have to be controlled. The ferritin value is inthe normal range when it amounts to 400 μg/1±50%. The transferrinsaturation should amount to 20-40%.

The invention will be illustrated hereinafter in more detail on thebasis of working Examples.

EXAMPLE 1

Patients with manifest iron deficiency (ferritin <12 ng/ml, transferrinsaturation <15% and haemoglobin <12 g/dl) are given by infusion 5,000 Uof rhEPO once per week and 100 ml of a modified haemoglobin preparation,preferably DCL-Hb, three times per week. This treatment is repeated fora further five weeks until the values for ferritin, transferrinsaturation and haemoglobin or haemocrit lie in the normal range.

1. A pharmaceutical kit comprising: (a) an erythropoietin preparationthat provides active erythropoietin in an amount of from about 3,000 Uto about 7000 U, and (b) a preparation containing from about 50 ml toabout 100 ml of at least one modified hemoglobin so as to correspond tofrom about 100 mg to about 200 mg of Fe²⁺⁺; the erythropoietinpreparation and the modified hemoglobin preparation being packaged ineither a single container or two separate containers.
 2. The kit ofclaim 15, wherein the erythropoietin preparation and the modifiedhemoglobin preparation are each present in separate containers and indifferent forms of administration.
 3. The kit of claim 16 wherein theforms for administration are selected from forms for injection and forinfusion.